Reference Sites Network for Prevention and Care of Frailty ... · back 6 18.10.2017 RER-ASSR D 6.2...

Project title: Reference Sites Network for Prevention and Care of Frailty and Chronic

Conditions in Community Dwelling Persons of EU countries

Acronym: SUNFRAIL

Project ID: 664291

Call identifier: H2020-HP-PJ-2014

Project Coordinator: Regione Emilia-Romagna, Agenzia sanitaria e sociale regionale

D 6.2: Sunfrail Tools for the Identification of Frailty and Multimorbidity

Document title: Sunfrail Tools for the Identification of Frailty and Multimorbidity

Version: 09

Deliverable No.: D 6.2

Lead task

beneficiary Gérontopole

Partners Involved: RER-ASSR, R. Liguria, R. Piemonte

Author: M. Cesari, M. Maggio, E. Palummeri, S. Poli, M. Barbolini, G. Moda

Status: Final

Date: 10/01/2018

Nature1: R

Dissemination level CO

This publication is part of SUNFRAIL (project 664291), which has received

funding from the European Union’s Health Programme (2014-2020). The

content of this publication represents the views of the author only and is

his/her sole responsibility; it cannot be considered to reflect the views of the

European Commission and/or the Consumers, Health, Agriculture and Food Executive Agency or any other body of the European

Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it

1

For deliverables: R = Report; P = Prototype; D = Demonstrator; S = Software/Simulator; O = Other

For milestones: O = Operational; D = Demonstrator; S = Software/Simulator; ES = Executive Summary; P

= Prototype


Document history:

Version Date Author Comments

1 22/3/2016 Gérontopole, R. Liguria,

RER-ASSR D 4.2 - Draft Version

2 26/10/2016 RER-ASSR Presented during the SC

3 11/11/2016 Gérontopole, R. Liguria,

RER-ASSR Revised on the basis of partner feed back

4 18/11/2016 Gérontopole Further Revision

5 02/02/2017 RER-ASSR, PPs D 4.2 - Final Version on the basis of the EC feed-

back

6 18.10.2017 RER-ASSR

D 6.2 - Presented the Preliminary Results of the

Sunfrail Tool Experimentation during the SC in

Belfast

7 30/11/2017 Gérontopole Elaborates Methodology, Results and

Reccomendations

8 03/12/2017 RER-ASSR Further Revision

9 09/01/2018 RER-ASSR

Revised on the basis of partner feed back:

-Paola Obbia, Piemonte Region;

-Pasquale Abete, Azienda Ospedaliera

Universitaria Federico II of Naples;

-Tomasz Kostka, Lodz (Poland)

10 12/01/2017 RER-ASSR/Gerontopole Final Version submitted to the CE

The present report on the Sunfrail Tools for the Identification of Frailty and Multimorbidity (D 6.2) has

been developed building on the deliverable D 4.2 Sunfrail Tool for the Identification of Frailty and

Multimorbidity originally submitted to the EC during the first reporting period. This document has been

integrated with details of the methodology, results and outcomes of the experimentation of the tool. All

steps of development are described in the table above.

The description of all tools identified within the project on the identification, prevention and management

of frailty and care of multimorbidity are extensively described in the Experimentation Report D. 6.1.

The description of the Sunfrail Tool for Human Resources and related processes, methodology and

outcome are entirely described in deliverable D7.1 Educational Model for health Care Staff and related

Tools.


1

Table of Contents

1.Introduction ............................................................................................................ 2

2.Assessment of Perceptions, Instruments and Needs for the Identification and

Management of Frailty and Multimorbidity ............................................................... 3

3.Potential Innovative Solutions ................................................................................. 6

4.The Design of the Sunfrail Tool to Screen Frailty and Multimorbidity ..................... 6

5.From the Alert to the Validation and the Activation of Pathways of Care ............. 10

6.The Experimentation of the Sunfrail Tool .............................................................. 12

7.Sunfrail Tool Results .............................................................................................. 17

7.1 Suggested Pathways of Care ................................................................................................................. 24

7.2 Confirming the Responses of the Sunfrail tool by Secondary Level Services ........................................ 26

7.3 Potential For Replicability ...................................................................................................................... 27

7.4 Results of the Assessment of Professionals and Community Actors’ Opinion on the Use of the Sunfrail

Tool .............................................................................................................................................................. 29

8.Sunfrail Tool Main Findings ................................................................................... 30

9.Conclusions ........................................................................................................... 31

10.Sunfrail Tool References ...................................................................................... 32

11.Annexes .............................................................................................................. 35

Annex 1 - Results on the Understandability/Comprehensibility of the Sunfrail Tool (Gerontopole) ........ 35

Annex 2. Phase 3 - Assessment of Professionals and Community Actor Opinion on the Use of the Sunfrail

Tool – Methodology and Instruments ......................................................................................................... 38

Phase 3 - Results of the Assessment of Professionals and Community Actor Opinion on the Use of the

Sunfrail Tool ................................................................................................................................................. 43


2

1.Introduction

As foreseen by the project WP4, within the assessment of Reference Sites health and social services,

Sunfrail project carried out the assessment of the instruments used to identify frailty and multimorbidity in

Primary Health Care. Reference Sites report an extreme heterogeneity in the clinical assessment of the risk

profile of the older person, as the most common risk factors of frailty are not systematically explored (in

certain regions quite rarely), and are prioritized differently.

Moreover, the Reference Sites have no specific instrument implemented in the primary care routine. It is

more likely to have multiple instruments proposed (or also endorsed) by public health authorities, leaving

to the healthcare professional the choice of the most convenient one to use.

Taking into consideration all these aspects, a Sunfrail team composed by geriatricians, public health

experts, sociologists and other professionals have developed a tool for the early identification of frailty and

multimorbidity within primary care and community settings. The Sunfrail tool has been developed in close

collaboration with the European Union Geriatric Medicine Society (EUGMS) – Special Interest Group on

“Frailty in older persons”.

The tool, far from being exhaustive, encourages health, social and community actors to identify the key

indicators of frailty through a "minimum core of items" within the biomedical, psychological, individual and

socio-economical domains, and to generate a proactive response.

It is a first "easy to use" screening tool, usable by different professionals and also by informal carers within

health, social and community settings, allowing the generation of a first alert that would then imply:

a) the activation of a referral for further medical assessment and diagnostic investigation or

b) the activation of a response from the social sector and the community.


3

2.Assessment of Perceptions, Instruments and Needs for the Identification

and Management of Frailty and Multimorbidity

The rationale for developing the Sunfrail tool has been based on three different steps regarding:

a. The perception of the terms frailty and multimorbidity by the citizens and GPs, the perceived

difference between frailty and multimorbidity and the potential overlap of these two conditions.

b. The analysis of the instruments available in Reference Sites and moments of detection.

c. The assessment of the type of the responses used to counteract frailty and multimorbidity in

different settings (primary health and social care, community or Hospital) where the isolate or

combined approach to these conditions is needed.

a. The perception on the terms of frailty and multimorbidity by the citizens and GPs

The term frailty is mostly confined to geriatric world without a significant impact in clinical practice and

health care system. This term is often seen by patients, GPS and Public Health professionals in different

negative ways. Among older subjects, it is usually considered a bad term or an irreversible condition,

frequently inducing scare and aversion. In GPs’ view, frailty is not considered a true disease, and is often

perceived as the inevitable consequence of the single chronic disease and/or multimorbidity. The aging

process is a continuous and irreversible process potentially responsible for many age-related adverse

outcomes. In this context, frailty may represent a condition to be targeted by preventive and therapeutic

strategies in order to reverse some modifiable risk factors and promote independent life. As frailty is a

distinct concept than disability, it is important to develop interventions and tools aimed at early detection,

prevention and management of frailty conditions (Figure 1 and Figure 2).

Figure 1. Trajectories of Function in older persons


4

Figure 2. Frailty as distinct concept than Disability - The Need of Simple Tools to identify this condition

There is growing attention among medical disciplines including oncologists, cardiac surgeons, cardiologists,

urologists, and haematologists about the opportunity to identify specific frail vulnerable subjects in order

to start tailored interventions.

Multimorbidity is defined by WHO as the presence of two or more chronic diseases, independent of the

severity and of the presence of specific clusters. It is a very monodimensional construct, centered on

diseases rather than on the person, potentially introducing a bias in the proper evaluation of the individual.

A good proxy of multimorbidity is the polypharmacotherapy which is the consequence of multimorbidity

and is defined by the administration of 5 or more medications on regular basis. The challenge and

opportunity of Sunfrail Project is to move through all phases of the continuum of Frailty phenomenon from

the early detection of frailty to the management of chronic diseases.

b. The analysis of the instruments available by Reference Sites on frailty and multimorbidity

An analysis at three different steps was conducted in order to identify a suitable instrument for screening

physical and multidomain frailty and multimorbidity.

1. A web search literature using the terms frailty and multimorbidity and looking at instruments was

performed using the time-period limit between the years 2000 and 2015.

2. In all reference sites, information on good practices in the field of frailty and multimorbidity was

collected.

3. An assessment of Reference Sites health and social services, and particularly on the community

outreach, diagnosis and management approaches towards frailty and multimorbidity.


5

The review pointed out that even inside the same Reference Site, different and heterogeneous tools were

used, and in most of cases, not validated in the local languages.

The most frequent approach to frailty and multimorbidity is often a separate assessment without

integration between the number and/or type of chronic diseases and functional status. The stratification of

multimorbid older persons is in some cases available from administrative data (Emilia-Romagna, Northern

Ireland) and is usually oriented to address the role of chronic diseases in determining the risk of

hospitalization and mortality of adult-older persons. There are not structured and planned moments of

contacts with older person (for example vaccinations or others) where the combined detection of frailty

(usually physical) and multimorbidity is routinely performed in the Primary Health and Social Care,

Community setting. There are no progressive levels of evaluation and assessment, from the primary health

and social care to the hospital, addressing frailty and multimorbidity and able to generate tailored and

proactive interventions.

Therefore, there is need of “easy to use” and multidomain screening tools or questionnaires combining

biological/physical, social and psychological/cognitive aspects of frailty and multimorbidity. The

administration of these instruments should allow the identification and activation of early and proactive

responses.


6

3.Potential Innovative Solutions

Educational strategies aimed a) to underline the reversibility of frailty and the high priority of the early

detection and management of this condition b) to address the importance of multimorbidity not only in

terms of number of diseases but also in terms of severity c) to consider multimorbidity not separately

from frailty.

Easy to use and multidomain screening tool for frailty and multimorbidity, focusing on detection and

inducing proactive responses.

To provide structured moments for the identification of frailty and multimorbidity combined and

adopted by different professionals.

To organize structured models and responses to these conditions by creating a Territory-Hospital

Platform.

4.The Design of the Sunfrail Tool to Screen Frailty and Multimorbidity

A Working Group was created to build-up an instrument aimed to identify and manage frailty and

multimorbidity in non-institutionalized older persons. The group was composed of one sociologist and

three geriatricians and public health experts of three different reference sites. The idea underlying the

composition of the group was to combine the expertise in multidimensional comprehensive geriatric

assessment, sociological and public health fields and to take advantage from the experiences generated in

pivotal studies conducted in Toulouse, Genova and Parma.

The aim of the group was to create an easy to use questionnaire by any professional figure (Nurse, Social

Worker, GPs,) or in-formal Caregiver adequately trained and in different settings (primary health and social

care, community and hospital).

The Bio-Psycho Social Paradigm was the inspiring model. The rationale for identifying the items to include

in the questionnaire was based on the bio-physical, psychological-cognitive and social- economic domains,

and on the questions already available in the instruments adopted in the literature.

9 items (2 in the socio-economic domain, 2 in the Psychological-Cognitive domain, 5 in the Biological

Physical domain) were generated, discussed within the Sunfrail consortium and with external groups of

different Professionals, including the European Working Group on Frailty of the European Union Geriatric

Medical Society (Figure 5).


7

Figure 5. Sunfrail tool for the Early Identification of Frailty and Multimorbidity

Bio-Physical Domain – Five specific questions addressing the areas of malnutrition, walking and physical

function, falling, regular GP visits and number of regular medications were selected in the bio-physical

domain. “Have you lost weight during the last year such that your clothing has become looser?” was the

first item evaluating the importance of weight and weight loss as important parameters of the physical

status and related changes during the last year. This item can have important consequences in terms of

physical function if not adequately addressed and treated. Walking is the proxy of the general health status

of older individual, and the slow walking speed, especially 4-meter (<0.8 meters/sec), has been shown in

different studies as an important predictor of adverse health outcomes in older persons (Studenski S. et al.

JAMA. 2011; 305:50-8). The ability, but also the habit of walking, might depend on different barriers

including weather, social isolation, and lack of transportation. Thus, the item “Your physical state made

you walking less during the last year?” was selected in order to address the causal link between the

physical status and reduced walking and finally, we chose the “falling event”, because it is a critical

sentinel/event in the risk of frailty and disability. The statuses of faller and recurrent faller are both

addressed in the question “Have you fallen 1 or more times during the last year?”. It should be underlined

that fall has also relevant psychological implications in addition to the well-known physical consequences.

Another important issue in terms of heath care and preventive strategies is the frequency of the access or

regular visits performed by GPs during the year. In most of EU Countries the access to GPs is not only

devoted to check just physical health-related problems but also directed to explain and communicate social

pending issues. This explains the rationale of choosing the item “Have you been evaluated by your General

Practitioner Physician during the past year?” as proxy of what this subject has been monitored in terms of

physical/biological and social aspects. In the physical domain we decided to include a clinical item more

related to multimorbidity/polypharmacotherapy. Two different options, number of chronic diseases and

the number of medications, were discussed inside the group. We argued that in the real clinical world the

reporting of number of diseases is much more difficult to be performed by older persons. They might have

more difficulties to remind the type of diseases but are definitively more familiar with the number and type

of medications taken on regular basis.

Number of medications is much more relevant even though the confounding effect of occasional and

temporary medications, supplements should be taken into account. That’s why the final choice, based also

on the available items in the literature, was “Do you regularly take 5 or more medications per day?”.


8

Psychological Cognitive Domain – the cognitive and psychological domain were tested by 2 questions:

“Have you experienced memory decline during the last year?”.

We are aware that changes and symptoms of memory decline may occur later than expected during the

course of dementia, but it is rarely systematic tested even with a single question. It should be underlined

that it is present in other questionnaires available in the literature. The other item “Do you feel lonely

most of the time?” already described in the social domain can be surely also considered a psychological

one. As above mentioned, recent epidemiological studies support the more powerful ability of the

loneliness to predict the risk of frailty in older population. (Soysal P. et al. Ageing Res Rev. 2017 Jul;36:78-

87).

Socio-economic Domain – The group selected 3 questions specifically addressing the Social Domain. The

first question is aimed to address whether the older individual feels really alone independent of the real or

potential presence of relatives and/ or other caregivers. The question “Do you feel lonely most of the

time?” was chosen because more exhaustive and solid than “Do you live alone?” available in other

questionnaires (Perissinotto C. et al. Arch Intern Med. 2012; 172(14):1078-1084), as loneliness has been

shown to be a more powerful predictor of functional decline and death in older persons than social

isolation (Gale CR. et al. Age and Ageing. 2017; 0:1-6).

To live alone in fact might be a misleading concept being a specific choice of the individual and not implying

a proxy of social frailty. In addition, the experience from different reference sites suggests that sometimes

the condition of living alone is an erroneous and inadequate proxy the real-life condition. The older persons

may not declare the presence of assistant /caregivers because of taxes or other economic issues. The

second question on the social domain is “In case of need, can you count on someone close to you?”. This

item addresses the important concept of the resilience or the ability of the individual to cope with change

or changed need” and can adequately address the important value of the “social reserve”. The third

question is “Have you any economic difficulty in facing the basic expenses and the health care costs?”, old

and more recent data suggest that low income and economic difficulties are independent predictors of

survival and a key factor in favouring preventive strategies in older persons (Chetty R et al. JAMA. 2016;

315(16):1750-1766).

The Sunfrail Tool, above described, should address different issues with the goals:

a. To be flexible enough and compatible with the different instruments/questionnaires already

available in the different Reference Sites;

b. To be easily administered by Any Professional (Nurse, Social Worker, GPs, Pharmacists) and

informal Caregiver adequately trained;

c. To generate alerts otherwise never detected but that need to be validated by the different

Professionals present in the Multiprofessional team;

d. To induce, once the alerts are confirmed, proactive mono or multidomain interventions based

on the resources already available in the Reference Sites.


9

According to the bio-psycho social domains of frailty and the importance of responding to

patients/beneficiaries needs to maintain independence, a first priority is to work on the assessment of

frailty risk factors and its prevention. As indicated in the Sunfrail Tool Conceptual Frame below (Figure 6),

this can be done through a “multiple entry door system”, where frailty and its risk factors can be identified

through health, social and community-informal system. By using the Sunfrail Tool, professionals and

community actors opportunely trained may identify frailty and its risks, and activate an initial “alert” for

further prevention activities, professional/specialist and diagnostic investigation.

Figure 6. Sunfrail Tool Conceptual Frame


10

5.From the Alert to the Validation and the Activation of Pathways of Care

Different scenarios and pathways of care may emerge after the administration of the Sunfrail Conceptual

Frame and Tool, according to the different alerts generated and their confirmation (Figure 7).

Figure 7. Flow-Chart - Potential Scenarios Emerging from the Administration of the Sunfrail tool.

The Subject 1 has no alert generated by 9 item Sunfrail tool and does not require additional

evaluation during the short term period.

The Subject 2 has only alert in one or more items of socio-economic domain with positivity at

item 7, 8 and 9. The Social workers working in the primary health care or community settings

are the main actors that need to be activated in order to provide a response to these alerts.

The Professional Figure may contact the subject and, if he/she agrees, plan a home-visit to

verify all needs and generate all the responses required. For instance, social taxi, help in

preparing food, activation of volunteer network. The other professional figures working in the

team (GPs and Community Nurse) need to be informed and involved.

The Subject 3 has alerts in Psychological cognitive Domain addressed by positivity at 1 of the

items 6 and 7. The Community Nurses and GPs, and Social worker working in the primary

health care settings, need to confirm the alert with the administration of specific tests

including General Practitioner assessment of Cognition (GPCOG) more oriented to address the

Cognitive Domain. If the alert is confirmed, GPs can schedule a second level

Neuropsychological Assessment.

The Subject 4 has in 1 or more Positivity at 1,2,3,5 items and/or did not receive any General

Practitioner assessment during the past year (Negative response at item 4). He/she should


11

undergo additional evaluation by Community Nurse and GPs (Item 4) to confirm these alerts.

Mini Nutritional Assessment Short Form (Item 2), 4 meter gait speed with a manual

chronometer and Hand grip strength (dynamometer) (Item 3) and Revision of Therapeutic

plan and adherence to current pharmaceutical treatment (Item 1) are the minimum tests

required to confirm the Frailty in Physical Domain (Minimum Comprehensive Geriatric

Assessment CGA). Short Physical performance Battery (SPPB), and Timed up and go would be

of particular utility to better inquire the risk of falling (item 5), together with PASE

questionnaire or assessment of physical activity by Professional physical activity logger (when

available) (Full CGA). These assessments are easy enough to be performed in the Primary

Health and Social Care, Community or in the Hospital according to the different profile and

Organizing Model existing in the Reference Sites (Figure 6). Once the single item of physical

frailty is confirmed, specific tailored interventions including programs of resistance exercise,

nutritional interventions with nutrients (whey proteins, vitamin D, leucine) already known to

increase muscle strength, additional tests to address the cause of weight loss, revision of

medications list in order to address adherence to treatment, interactions between treatment

and appropriateness according to guidelines available and specifically targeting older persons

and healthy active lifestyle education programs aimed at improving and monitoring aerobic

exercise and physical activity, and nutritional habit might be activated.

The Subjective 5 can have alerts in the 3 different domains. In this case, the multi-professional

intervention already described in separate profiles can be activated.

All this information should be integrated with the administrative data, when available, in order to combine

the assessment of frailty with different degree of severity of multimorbidity and to target different

outcomes, including the risk of hospitalization and death, and activating specific plans of individual

assessment and treatment according to disease and case management approach.

Moments of Interceptions: two different approaches can be followed to intercept frailty and

multimorbidity. In Reference Sites where the administrative data are sensitive enough to collect

information on risk profile of older populations (hospitalization and death), the items selected by the

Sunfrail questionnaire can be added. Alternatively (or in addition), structured events including vaccination,

educational moments such as obesity week and nutrition days, or informal routinely events including

access to malls, pharmacies, churches, post-offices, specialists waiting rooms can be used to administer the

questionnaire and to activate the other phases. These two approaches could be combined.


12

6.The Experimentation of the Sunfrail Tool

In order to prepare the experimental phase of the project, the consortium elaborated a protocol to test the

Sunfrail tool in participating Reference Sites. The objective was to verify its adaptability, understandability

and applicability into the current professional practice.

It included the following phases:

1. Translation and back translation of the Sunfrail tool into all languages spoken in the

participating sites;

2. Verify the understandability/comprehensibility of the Sunfrail tool by beneficiaries and

professionals;

3. Verify the applicability of the Sunfrail tool into the current professional practice;

4. Analysis and interpretation of the Results;

5. Assessment of the professionals’ opinion on the applicability and transferability of the Sunfrail

Tool.

Phase 1. Translation and back translation of the Sunfrail tool

The Sunfrail tool was translated and back translated by native speakers from English into all languages

spoken in the participating sites (Italian, English, French, Polish, Spanish), and cross-culturally adapted to

make sure that the original meaning of the items was fully understood.

Phase 2. Verify the understandability/comprehensibility of the Sunfrail tool

The understandability of each item/question of the questionnaire was checked by R Liguria, Gerontopole,

Northern Ireland and Poland in their respective languages. Each item/question of the questionnaire was

tested with a group of 10 professionals and community actors and 20 beneficiaries for each reference site

and a score attributed (Understandable, not Understandable), for each potential option. Results indicated a

very good understandability by beneficiaries and by professionals. Suggestions for improvement were

adopted, in order to finalize the tool in all languages spoken in the participating sites (see results in Annex

1).

Phase 3. Verify the applicability of the Sunfrail tool into t he current professional

practice (Experimentation)

The assessment of the applicability of the Sunfrail tool into the current professional practice has been

conducted by 5 Reference Sites (R. Liguria, R. Campania, Lodz Poland, Northern Ireland, Deusto-Spain).

Reference Sites have selected different experimentation settings based on their organizational structure. In

some cases the administration of the tool has occurred within community and primary care settings, while

based on specific organizational set-up other RS have administered the tool within secondary care settings

(outpatients departments).

A number of at least 100 beneficiaries (age group 65-74 and 75-85) were selected in order to be assessed

by each reference site. Professionals (nurses, social workers, GPs) and community actors have administered


13

the Sunfrail tool into their daily practice by collecting the responses and registering the results (option yes

and no).

The applicability of the Sunfrail tool into the current professional practice was tested by adopting the

following instruments:

a. Sunfrail Tool for the Experimental Phase – Alert Generation.

b. Flow Chart - Potential scenarios emerging with the administration of the Sunfrail tool.

c. Suggested Care Pathways.

The alerts generated by the administration of the Sunfrail Tool (Figure 8) were assessed through the flow-

chart (Figure 7), used to identify specific care pathways among Reference Sites available services (Figure 9),

or in alternative to point out their specific needs.


14

Figure 8. Sunfrail Tool for the Experimental Phase – Alert Generation

QUESTIONNAIRE NUMBER

Date and place

PROFESSIONALS

Professional □ Nurse □ GPs □ Other Professionals

□ Social Worker □ Community Actor □ Caregiver

BENEFICIARIES

Gender

□M

□F

Age

□65-74

□75-85

Level of education

□ Low (Without studies, Primary School)

□Medium (Secondary school, or vocational

degree)

□ High (University, Master or PhD degree)

Questions

1. Do you regularly take 5 or more medications per day? □ Yes □ No

2. Have you recently lost weight such that your clothing has become

looser?

□ Yes

□ No

3. Your physical state made you walking less during the last year? □ Yes □ No

4. Have you been evaluated by your GP during the last year? □ Yes □ No

5. Have you fallen 1 or more times during the last year? □ Yes □ No

6. Have you experienced memory decline during the last year? □ Yes □ No

7. Do you feel lonely most of the time? □ Yes □ No

8. In case of need, can you count on someone close to you? □ Yes □ No

9. Have you had any financial difficulties in facing dental care and health

care costs during the last year? □ Yes □ No


15

Figure 9. Suggested Care Pathways (multiple choices are allowed)

Request GP visit □

Request Specialist-Geriatrician evaluation □

Diagnostic Evaluation □

Proactive

&

Preventive

Interventions

Social Support

transportation for social

activity/services, Nutritional

Support, economic support,

leisure and community and social

activities

□

Physical Exercise □

Psychological and/or Cognitive

support □

Non-relevant □

Relevant but not available □

Additional information on partner experimental plans and related methodology is provided with the report

on the experimentation (6.1-A report on experimentation of the model, its transferability and

sustainability).

Reference Sites testing the Sunfrail tool at secondary level facilities have confirmed the responses obtained

from some items of the questionnaire by using specific confirmatory tests.

Phase 4 - Analysis and interpretation of the Results

The data obtained from the application of the Sunfrail tool has provided information on its capacity to

assess frailty risk profile of the selected population in different settings, and how the alerts generated can

support the selection of care pathways among the existent ones.

Phase 5 - Assessment of Professionals and Community Actor Opinion on the Use of the

Sunfrail Tool

The working group has also carried out an assessment of interviewers (professionals’/ community actors)

opinion on the use of the Tool, to check the compliance and the comments made while using and managing


16

the instrument and the ability to evocate proactive responses in the different Reference Sites participating

at the Experimental phase. The appraisal was conducted through the administration of a questionnaire

with open and closed ended questions. For further details see the questionnaire and the results in Annex 2.

The experimentation of the Sunfrail tool was conducted from February through September 2017.

Through the EU CoNSENSo project (COmmunity Nurse Supporting Elderly iN a changing Society-

http://www.alpine-space.eu/projects/consenso/en/home), the Sunfrail tool has been adopted also in other

EU countries/Regions (France, Slovenia, Austria). R. Piemonte contributed to the experimentation also by

developing the model and tool for Human Resources Development.

Beside the support provided for the design and implementation of all phases, given the promising results

obtained from the Sunfrail Tool, RER-ASSR has decided to conduct an additional specific study to validate

the Sunfrail tool (criterion and construct validity), by GPs and Multidimensional teams in community based

settings (Case della Salute). The results of this Study will be available by June 2018.

Phase 6 - Data Collection and Analysis

Data collected from the Sunfrail Tool was collated and entered onto a spreadsheet via SharePoint. RER-

ASSR analyzed the information collected and provided it to partners for further analysis and comments.

RER-ASSR also perform the data control and analysis on the results obtained from confirmatory tests of the

Sunfrail tool performed by Lodz, Federico II of Campania Region and Liguria Region.

http://www.alpine-space.eu/projects/consenso/en/home


17

7.Sunfrail Tool Results

The results obtained by the experimentation of the Sunfrail tool in different settings are summarized below

(assessment of the applicability into the current professional practice - Phase 3). These findings have been

anticipated at the recent Sunfrail Scientific Committee and Advisory Board meeting held in Belfast on

October 18, 2017.

The settings, where the questionnaire was proposed, changed from partner to partner, as described in the

table 1.

Table 1. Characteristics of the Setting and the Reference Sites

Reference Sites Setting

Deusto University (Spain) Primary health-social care

HSCB (Northern Ireland) Community-Primary health care

Medical University of Lodz (Poland) Community-Secondary care (outpatient department)

Galliera Hospital (Italy) Primary care-Secondary care (outpatient department)

University of Naples Federico II (Italy) Secondary care (outpatient department)

Regione Liguria/Piemonte (Consenso project) Community-Primary health care


18

Overall, a total of 651 participants were evaluated across the study sites with the Sunfrail Tool. 34,1% were

belonging to the age group 65-74 and 65,9% to the age group 75-85. 57, 14% were females and 42,86%

males. 18.89% had a higher education level, 48,39% a medium and 32.72% were belonging to the low

education level group (Table 2 and Figure 10, 11 and 12).

Table 2. Characteristics of the Study Population

Characteristics n=651 %

Deusto University, Spain Galliera Hospital, Italy HSCB, Northern Ireland Medical University of Lodz, Poland University of Naples Federico II, Italy

105 194 127 114 111

16.1 29.8 19.5 17.5 17.1

Women 372 57.1

Age groups 65-74 yo 75-85 yo

222 429

34.1 65.9

Education level High (University, Master or PhD) Medium (Secondary school) Low ( Primary school or lower)

123 315 213

18.9 48.4 32.7


19

Figure 10. The distributions of age-groups across the different Reference Sites

Figure 11. The distributions of gender across the different Reference Sites


20

Figure 12. The distribution of education level across the different reference sites

Table 3. Prevalence of the alerts reported by the beneficiaries after the administration of Sunfrail Tool

Questions N % 95%CI

1. Do you regularly take 5 or more medications per day? (YES)

329 50.5 46.7-54.3

2. Have you recently lost weight such that your clothing have become looser? (YES)

160 24.6 21.4-28.0

3. Has your physical status made you walking less during the last year? (YES)

347 53.3 49.5-57.1

4. Have you been evaluated by your GP during the last years? (NO)

80 12.3 10.0-15.0

5. Have you fallen one or more times during the last year? (YES)

199 30.6 27.2-34.2

6. Have you experienced memory decline during the last year? (YES)

323 49.6 45.8-53.5

7. Do you feel lonely most of the time? (YES) 173 26.6 23.3-30.1

8. In case of need, can you count on someone close to you? (NO)

51 7.8 6.0-10.2

9. Have you experienced any financial difficulties in facing dental or health care during the last year? (YES)

96 14.8 12.2-17.7


21

By considering all settings together, the higher proportion of frailty risk factors (alerts) applies to

Polypharmacy (50,5%), walking less because of physical status, (53.3%), and memory decline (49.62%) in

different settings (Table 3).

By considering the source of data of different setting (Secondary Care, Primary and Community), a sort of

“dose-response” was observed in the sequence Community-Secondary care with the subjects of Secondary

Care reporting the higher prevalence of positive answers.

Interestingly, a high proportion of the frailty alerts, especially for questions 1, 3, 5 and 7 was also found in

Community - Primary Care; settings more likely to have a population without evident signs of disability or

unknown by services (Table 4).

Table 4. Prevalence of the alerts reported by the beneficiaries after the administration of Sunfrail Tool in 3 different settings

Questions

Total n=651 Secondary Care (Outpatient)

(n=161)

Primary Care n=363

Community n=127

% % % %

1- Do you regularly take 5 or more medications per

day? 50,54 65,22 42,7 54,33

2- Have you recently lost weight such that your

clothing has become looser? 24,58 36,02 21,76 18,11

3- Your physical state made you walking less during

the last year? 53,3 64,6 46,83 57,48

4- Have you been evaluated by your GP during the

last year? (NO) 12,29 10,56 11,85 15,75

5- Have you fallen 1 or more times during the last

year? 30,57 42,86 29,48 18,11

6- Have you experienced memory decline during the

last year? 49,62 60,87 55,37 18,9

7- Do you feel lonely most of the time? 26,57 31,06 26,72 20,47

8- In case of need, can you count on someone close

to you? (NO) 7,83 8,7 9,37 2,36

9- Have you had any financial difficulties in facing

dental care and health care costs during the last

year?

14,75 22,98 14,88 3,94


22

These results were confirmed after the analysis stratified of the population according to the different reference site (Table 5). In bold, the problem most frequently reported by the participants in each reference site. In italic, the least prevalent in each reference site. Table 5. The prevalence of positive answers to the items included in the Sunfrail Tool, stratified by reference site

Questions Deusto n=105

Naples n=111

Lodz n=114

HSCB n=127

Liguria n=194

1. Do you regularly take 5 or more medications per day? (YES)

35.2 68.5 53.5 54.3 44.3

2. Have you recently lost weight such that your clothing have become looser? (YES)

23.8 42.3 14.9 18.1 24.7

3. Has your physical status made you walking less during the last year? (YES)

45.7 70.3 46.5 57.4 49.0

4. Have you been evaluated by your GP during the last years? (NO)

8.6 10.8 12.3 15.8 12.9

5. Have you fallen one or more times during the last year? (YES)

24.8 43.2 36.8 18.1 30.9

6. Have you experienced memory decline during the last year? (YES)

50.5 64.0 51.8 18.9 59.8

7. Do you feel lonely most of the time? (YES)

33.3 34.2 19.3 20.5 26.8

8. In case of need, can you count on someone close to you? (NO)

15.2 10.8 6.1 2.4 6.7

9. Have you experienced any financial difficulties in facing dental or health care during the last year? (YES)

13.3 28.8 12.3 3.9 16.0

In general, the oldest group of participants had a higher prevalence of positive (Q1, Q2, Q3, Q5, Q6, Q7, Q9)

and negative response (Q2) than youngest age group. The difference between the 2 age-groups was

statistically significant for Q1 (polypharmacy) Q3 (walking less) Q4 (GP visit), Q6 (memory decline), Q7

(loneliness) and financial difficulties (Q9) (Figure 13).


23

Figure 13. Percentage of positive (or negative for Q4 and Q8) answers to the Sunfrail Tool by Age-group categories (65-74 in orange and 75-85 in grey)

Figure 14. Percentage of positive (or negative for Q4 and Q8) answers to the Sunfrail Tool by Education Level

Participants with a lower education level were also more likely to be positive at the different Sunfrail

questionnaire items (Figure 14). The relationship is statistically significant especially for functional decline,

followed by feeling lonely, polypharmacy and financial difficulties. Beneficiaries with lower educational

level have also greater financial difficulties of access; thus with potential greater equity problems.


24

7.1 Suggested Pathways of Care

Based on the alerts generated by the application of the Sunfrail tool and use of the flow-chart, specific care

pathways were identified among available services, ranging from further diagnostics and specialist

assessments, proactive interventions and social support; or in alternative to point out its need.

Table 6. The pathways activated after the alerts generated by the administration of the Sunfrail Tool

Suggested pathways n % 95%CI

GP’s evaluation 137 21.0 18.1-24.3

Specialist’s evaluation 183 28.1 24.8-31.7

Diagnostic procedure 74 11.4 9.2-14.0

Physical exercise 358 55.0 51.2-58.8

Psychological/Cognitive support 205 31.5 28.0-35.2

Social support 163 25.0 21.9-28.5

Other 173 26.6 23.3-30.1

Not available 5 0.8 0.3-1.8

Non-relevant 19 2.9 1.9-4.5

The table 6 above describes the interventions suggested by the healthcare, social care professionals and

community actors to beneficiaries reporting one or more frailty issue.

Overall, an important variability was found among suggested pathways across reference sites; mainly

depending on the settings in which the tool was administered.

Beneficiaries with biological and neuro-psychological alerts were generally referred for further assessment

or diagnostic investigation. The alerts of the biological domain brought to recommended

specialist/diagnostic evaluation and the alerts of the Neuropsychological to psychological and cognitive

support.

Community actors mainly advised beneficiaries to visit their GPs for further diagnostic assessments and/or

preventive actions.

In terms of preventive activities, physical exercise, counselling and promotion were suggested to a good

proportion of beneficiaries.


25

Overall, the Sunfrail tool demonstrates that it supports selection of existent pathways of care, and due to

its biological, psychological and socio-economic dimensions fosters integrated care between services

(health, social and community).

Figure 15. Activation of specialist and diagnostic evaluation according to positivity of Q1, Q3 and Q5 (physical frailty) or Q6 and Q7 (Neuropsychological Frailty)

In Figure 15, are reported respectively the pathways of specialist and diagnostic evaluation and of

psychological and cognitive support suggested after the positivity to questions Q1, Q3 and Q5 (Biological

Frailty) and Q6 and Q7 (Neuropsychological frailty). Interestingly, the multiple positivity to all 3 “biological”

questions and to 2 “neuropsychological” items was associated to a higher prevalence of pathways

activated.


26

7.2 Confirming the Responses of the Sunfrail tool by Secondary Level Services

Table 7. Difference of the Means in the Confirmatory tests score of Questions number 1, 3 and 6 stratified by Reference Site

Fed. II of Campania n=101 Lodz n=114 Liguria Region N=194

Questions n mean sd diff* 95% CI p n mean ds diff* 95% CI p n mean sd diff* ic95% p-value

1- Do you regularly take 5 or

more medications per day?

n. medications

per day

no 33 2,818 1,467 17 3,529 1,772 109 2,954 1,734

yes 68 7,529 2,216 4,711

3,886-

5,536 <0,0001 35 7,229 2,591 3,699

2,274-

5,124 <0,0001 85 7,082 2,117 4,119

3,575-

4,664 <0,0001

3- Your physical state made

you walking less during last

year?

4-m WS (0,8

m./sec.)

no 31 0,821 0,06 28 1,243 0,2047* 98 1,249 0,291

yes

70 0,365 0,127 0,456 0,408-

0,503 <0,0001 24 1,069 0,281 0,174

0,041-

0,307 0,033 94 0,995 0,305 0,254

0,169-

0,338 <0,0001

6- Have you experienced

memory decline during the

last year?

MMSE (<24)

no 34 25,621 4,123 23 29,348 1,071 76 27,79 2,271

yes

63 20,656 3,597 4,965 2,531-

7,399 0,002 29 28,655 1,518 0,693

-0,069-

1,455 0,082 117 26,684 3,458 1,091

0,198-

1,984 0,017

The table 7 describes how frailty alerts generated by some Sunfrail tool items (Q1, Q3 and Q6) can be confirmed by specialist’s tests (n. of medications, 4 meter

gait speed, MMSE) commonly performed during the Comprehensive Geriatric Assessment. The means of the score generated in the confirmatory tests were

significantly different in participants answering yes to Q1, Q3 and Q6. In particular, those participants who answered yes to Q1, Q3 and Q6 had higher number

of medications, higher gait speed and higher MMSE score than those who answered no. These values of two different groups were statistically different in

both Italian Reference Sites (R. Liguria, Fed. II of Campania) and Lodz Poland.


27

7.3 Potential For Replicability

7.3.1 Results from the Application of the Sunfrail Tool within the Consenso Project

The Sunfrail tool has been also adopted in other EU countries/Regions (France, Slovenia, Austria), through

the EU CoNSENSo project (COmmunity Nurse Supporting Elderly iN a changing Society-http://www.alpine-

space.eu/projects/consenso/en/home). Its results confirm the adaptability and replicability of the tool in

different settings, especially primary care and community.

Table 8. The prevalence of positive (or negative) answers in Sunfrail and Consenso Project

Questions Sunfrail n=651

CONSENSO

n=300

Item % %

1- Do you regularly take 5 or more medications per day? 50,54 44,00

2- Have you recently lost weight such that your clothing has become looser? 24,58 20,33

3- Your physical state made you walking less during the last year? 53,3 46,00

4- Have you been evaluated by your GP during the last year? (NO) 12,29 33,33

5- Have you fallen 1 or more times during the last year? 30,57 22,00

6- Have you experienced memory decline during the last year? 49,62 48,00

7- Do you feel lonely most of the time? 26,57 10,33

8- In case of need, can you count on someone close to you? (NO) 7,83 1,33

9- Have you had any financial difficulties in facing dental care and health

care costs during the last year? 14,75 18,67

7.3.2 Results of the Study conducted on the Sunfrail tool in the Netherlands by Prof. Gobbens

A pilot study was conducted on the Sunfrail tool in the Netherlands, by R. Gobbens. Its objectives were to

determine the associations between the Sunfrail tool and the Tilburg Frailty Indicator (TFI), and other

indicators of frailty and health care utilization.

A questionnaire was sent to 241 community-dwelling elderly aged 70 years and older living in the

Netherlands, of whom 156 completed the questionnaire (response rate 64.7%). The TFI was used to assess

total frailty and frailty in each domain (physical, psychological, social). Five indicators of health care

utilization were used: visit to a general practitioner, hospital admission, receiving personal care, receiving

http://www.alpine-space.eu/projects/consenso/en/home


28

nursing care, and contacts with health care professionals. The Pearson correlation coefficient was used to

determine the associations between the Sunfrail tool and the other variables.

The mean age of the participants was 77.1 years (SD 5.0). The Sunfrail tool total, and the biological and

neuropsychological domains were associated with the TFI total and the physical, psychological and social

domains. In addition, the Sunfrail tool score and the biological domain were associated with four and five

indicators of health care utilization, respectively. The Sunfrail neuropsychological domain was only

associated with contacts with health care professionals and the socio-economic domain with none of these

indicators.

This pilot study has shown that the Sunfrail tool was associated with the TFI, and many indicators of health

care utilization. The tool is a promising instrument to measure frailty in older people.

7.3.3 Results of the Study conducted on the Sunfrail tool in Italy by Prof. P. Abete and Dr. I.

Liguori

In Campania, at the Azienda Ospedaliera Universitaria (AOU) “Federico Il”, Sunfrail tool was administered in

111 outpatients admitted to the “Geriatric Evaluation Unit” subjects for a Comprehensive Geriatric

Assessment (CGA). The CGA consisted of several multidimensional tools including the evaluation of

cognitive impairment (Mini Mental State Examination), depression (Geriatric Depression Scale), disability

(Basic and Instrumental Activity Daily Living), and comorbidity (Cumulative Illness Rating Scale). After the

CGA, the Italian version of Frailty index (IFi) together with Sunfrail tool was administered. The IFi has

recently been validated and includes 40 items, which explore the 4 domains of frailty: physical, mental,

nutritional and social. The latter two domains are investigated in the IFi by changing the item #24 (feel

lonely) and item #39 (usual pace) of “frailty index” with the “Social Support Scale” (SSS) and the “Mini

Nutritional Assessment” (MNA), respectively (Abete P et al. AGING CLIN EXP RES. 2017;29(5):913-926.). A

linear regression analysis between the two tools was performed and a good linear correlation (r=0.67,

p<0.001) was found. This analysis supports that SUNFRAIL tool can be used for frailty evaluation in a fast

way and by non-geriatricians or specialists with the same efficacy as the IFi.


29

7.4 Results of the Assessment of Professionals and Community Actors’ Opinion on the Use of the

Sunfrail Tool

The assessment of professionals and community actor opinion on the use of the Sunfrail Tool was

performed between October and November 2017 in the reference sites of Lodz, HSCB, Deusto, R. Liguria,

Fed. II of Campania by administering a short questionnaire, with the aim to assess:

1. Whether the tool was suitable to identify the domains of frailty and to activate care pathways;

2. Whether it was easily understandable and applicable during the daily professional/care

practice;

3. Whether it needed to be modified/improved and how.

The questionnaire included closed and open-end questions and was completed in English. HSCB processed

the answers and provided the data to RER-ASSR for the analysis.

24 persons were interviewed: 6 from Lodz; 2 from HBSC; 2 from Deusto; 8 from Campania and 6 from

Liguria. 17 were Health Professionals and 6 Community Actors; 1 did not answer to the question.

Main Key Findings

The tool is a friendly instrument, easy to apply; its questions are simple to be understood

and encourage a more in-depth dialogue. Thanks to the short “application time”, it is non-

invasive and allows the use in everyday practice.

The training is proved to be useful and important for both health professionals and

community actors, in particular to clarify the conceptual model based on the multi-domain

nature of frailty; the care-pathways to be suggested/activated and the information on how

to access the different territorial services.

The tool can help identifying early frailty signs, to be explored with further interventions/

assessments. When approaching the beneficiaries, it is important to pay attention to the

cultural and social context of application.

The tool can improve beneficiaries’ awareness, encouraging them to move from a

“disease” oriented vision to a proactive and preventive approach.

It is important to map the local network of services and community resources, in order to

activate sustainable and accessible care pathways.

Further details of the assessment are included in the Annex 2.


30

8.Sunfrail Tool Main Findings

The data obtained from the application of the Sunfrail tool has provided information on its capacity to

assess frailty risk profile of the selected population in different settings, and how the alerts generated can

support the selection of care pathways among the existent ones.

The Sunfrail tool allows identifying frailty risk alerts in the population over 65 of community dwelling

settings. The most frequent alerts detected in all settings were on functional decline, memory decline and

polypharmacy items in all settings, particularly in Community - Primary Care Settings. As the Sunfrail tool

was tested on a target population without any evident sign of physical and cognitive disability, these alerts

confirm the ability of the tool to increase the awareness on frailty risk factors in the population at low-

medium risk of disability.

In addition, the Sunfrail tool allows identifying the population with major risk for inequalities, as citizens

with a lower education level showed a higher prevalence of frailty alerts and greater financial difficulties in

accessing health services.

Interestingly, frailty alerts on polypharmacy, functional decline and memory decline items are confirmed by

specific tests ( clinical history of the patient with n. of medications per day, 4 meter walking speed and

MMSE), suggesting that frailty alerts could be further confirmed by GPs and multiprofessional team already

in primary care settings.

The Sunfrail tool, after confirmation of the alerts by clinical and social judgment, supports the usefulness of

selecting existent pathways of care. Given the biological, psychological and socio-economic dimensions

addressed by the tool, fosters integrated care between services (health, social, community), or in

alternative highlights gaps in service provisions.

The application of the Sunfrail tool allows bridging the gap between services offer and access especially in

primary care and community settings. This goal can be reached by improving beneficiaries awareness on

their risk factors and on services available and by promoting multi-professional involvement and the

integration between available services.

Overall, the majority of Sunfrail Good Practices are mainly used for the identification and management of

high and very high risks conditions, with a consequent higher burden on health care services and related

costs. The application of the Sunfrail tool complements these approaches, by allowing early identification of

the population with medium-low risk to orient a proactive approach based on prevention.


31

9.Conclusions

Frailty is a reversible condition, and needs to be addressed through its main dimensions

and early identification of risk factors, to orient proactive and preventive strategies.

Frailty alerts can be identified especially in community and primary care settings,

targeting a population that may be unknown by services.

Frailty risks factors can be found especially in citizens with lower educational level; this

may influence their access to care. Equity and affordability of preventive services need

to be carefully addressed by policy makers and services planners.

Frailty requires operational multi-professional and integrated strategies connecting

existent health, social and community services. This will help to provide more efficient

and cost-effective responses across services and sectors, bridging the gap between

peoples’ needs and services provision.


32

10.Sunfrail Tool References

• 1. Do you take 5 or more medications per day? Rolfson DB, et al. Validity and reliability of the Edmonton Frail Scale. Age

Ageing. 2006;35(5):526–529.

Scott IA, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA

Intern Med. 2015 May;175(5):827-34.

Di Bari M et al. Screening for frailty in older adults using a postal questionnaire: rationale,

methods, and instruments validation of the INTER-FRAIL study. J Am Geriatr Soc. 2014

Oct;62(10):1933-7

• 2. Have you recently lost weight such that your clothing has become looser? Rolfson DB, et al. Validity and reliability of the Edmonton Frail Scale. Age

Ageing. 2006;35(5):526–529.

• 3. Have you recently experienced any worsening of your mobility due to physical state? Raîche M, et al. PRISMA-7: a case-finding tool to identify older adults with moderate to

severe disabilities. Arch Gerontol Geriatr. 2008; 47(1):9-18

• 4. Have you been evaluated by a healthcare professional during the past 12 months? Gobbens RJ et al. Testing and integral conceptual model of frailty. J Adv Nurs. 2012

Sep;68(9):2047-60

•

• 5. Have you experienced one or more fall events during the past 12 months? Hebert R et al. Predictive validity of a postal questionnaire for screening community-

dwelling elderly individuals at risk of functional decline. Age Ageing. 1996; 25(2):159-67



Oct;62(10):1933-7


33

• 6. Have you experienced a memory decline during the past 12 months? Deokar AJ et al. Increased Confusion and Memory Loss in Households, 2011 Behavioral Risk

Factor Surveillance System. Prev Chronic Dis. 2015;12:140430.

Vellas B et al. Looking for frailty in community-dwelling older persons: the Gérontopôle

Frailty Screening Tool (GFST). J Nutr Health Aging 2013 Jul;17(7):629-31

Gobbens RJ et al. Testing and integral conceptual model of frailty. J Adv Nurs. 2012

Sep;68(9):2047-60



Oct;62(10):1933-7

7. Do you feel lonely most of the time?

Bielderman A, et al. Multidimensional structure of the Groningen frailty indicator in

community-dwelling older people. BMC Geriatr. 2013;13:86.

Steverink N, et al. Measuring frailty: developing and testing of the Groningen frailty

indicator (GFI). Gerontologist. 2001;41(1):236–7.

• 8. In case of need, can you count on someone close to you? Hebert R, et al. Frail elderly patients. New model for integrated service delivery.

Can Fam Physician. 2003; 49:992-7

Hebert R et al. Predictive validity of a postal questionnaire for screening community-

dwelling elderly individuals at risk of functional decline. Age Ageing. 1996; 25(2):159-67

Jylha M, Saarenheimo M. Loneliness and ageing. Comparative perspectives

In: The SAGE Handbook of Social Gerontology. Chapter 24. Dale Dannefer & Chris

Phillipson. 2010

Raîche M, et al. PRISMA-7: a case-finding tool to identify older adults with moderate to

https://www.ncbi.nlm.nih.gov/pubmed/12943358


34

severe disabilities. Arch Gerontol Geriatr. 2008; 47(1):9-18

9. Have you had any financial difficulties in facing dental care and health care costs during the

last year?

• Self-reported unmet needs for medical examination by sex, age, detailed reason and income quintile • Self-reported unmet needs for dental care by sex, age, detailed reason and income quintile OECD Health Statistics, extracted on 29 January 2015


35

11.Annexes

Annex 1 - Results on the Understandability/Comprehensibility of the Sunfrail Tool

(Gerontopole)

CHU-TOULOUSE

1.1 Summary of tests done with professionals (from Table 1)

NUMBER OF TESTS PERFORMED PER PROFESSIONAL TYPE

Summary

table Nurse GP

Social

worker Caregiver

Community

actor

Other

professionals

Profession 2 1 1 0 5 1

Total tests 10

Number of answers per question:

PROFESSIONALS: TEST OF UNDERSTANDABILITY OF SUNFRAIL TOOL

Questions Understandable Ambiguous

Indicate the total number of answers per question Yes No Yes

1. Do you regularly take 5 or more medications per day? 10 0 0

2. Have you unintentionally lost weight during the past

year such that your clothing has become looser? 10 0 0

3. Your physical state made you walk less during the past

year? 10 0 0

4. Have you been seen by your GP during the past year? 9 0 1

5. Have you fallen 1 or more times during the past year? 9 0 1

6. Have you experienced any memory decline during the

past year? 9 0 1

7. Do you experience loneliness most of the time? 10 0 0

8. In case of need, can you count on someone close to

you? 10 0 0

9. Have you had any economic difficulty in facing dental

care and health care costs during the past year? 10 0 0

Total 87 0 3*


36

*Please note that all the three ambiguities reported were due to a poor formulation in the French

translation of the sentence and not on the contents of the item.

1.2 Summary of tests done with beneficiaries (from Table 2).

NUMBER OF TESTS PERFORMED PER BENEFICIARY TYPE

Gender Age Education

65-75 75-85 Low Medium High

Men 4 4 2 4 4

Women 6 6 3 4 3

Total 10 10 6 10 4

BENEFICIARIES: TESTS OF UNDERSTANDABILITY OF SUNFRAIL TOOL

Questions Understandable Ambiguous

Indicate the total number of answers per item Yes No Yes

1. Do you regularly take 5 or more medications per day? 20 0 0

2. Have you unintentionally lost weight during the past

year such that your clothing has become looser? 20 0 0

3. Your physical state made you walk less during the past

year? 20 0 0

4. Have you been seen by your GP during the past year? 20 0 0

5. Have you fallen 1 or more times during the past year? 20 0 0

6. Have you experienced any memory decline during the

past year? 20 0 0

7. Do you experience loneliness most of the time? 20 0 0

8. In case of need, can you count on someone close to

you? 20 0 0

9. Have you had any economic difficulty in facing dental

care and health care costs during the past year? 20 0 0

Total 180 0 0


37

1.3 Suggested Revisions to the Sunfrail tool.

Based on the outcome of the test of understandability performed on professionals and beneficiaries,

if considered relevant, please suggest revisions to the questions proposed for the Sunfrail Tool.

Questions

1. Do you regularly take 5 or more medications per day?

No comments

2. Have you unintentionally lost weight during the past year such that your clothing has

become looser?

No comments

3. Your physical state made you walk less during the past year?

No comments

4. Have you been seen by your GP during the past year?

No comments

5. Have you fallen 1 or more times during the past year?

No comments

6. Have you experienced any memory decline during the past year?

No comments

7. Do you experience loneliness most of the time?

No comments

8. In case of need, can you count on someone close to you?

No comments

9. Have you had any economic difficulty in facing dental care and health care costs during the

past year?

No comments


38

Annex 2. Phase 3 - Assessment of Professionals and Community Actor Opinion on the Use of the

Sunfrail Tool – Methodology and Instruments

The assessment of professional and community actor opinion on the use of the Sunfrail Tool will be

performed by administering short questions through a Word document to be completed. It aims to assess:

a) Whether the Sunfrail tool is suitable to identify the domains of frailty and to activate care pathways;

b) Whether it is easily understandable and applicable during the daily professional/care practice; c) Whether it needs to be modified/improved and how.

Lodz, HSCB, Deusto, R. Liguria, Fed. II of Campania and RER-ASSR will participate to the assessment. It is

anticipated the involvement of at least three professionals/three community actors by each Centre would

be required.

The questionnaire will cover the following aspects:

PART I - Information about the person filling the form

PART II – Utilization of the Sunfrail Tool

PART III - Applicability and impact of the Sunfrail Tool

The questionnaire must be completed by return of a Word document. It includes closed-end questions and open end questions (with a maximum of 300 characters for each field).

The questionnaire will be in English. Participants are free to translate it and answer in their own language.

Each Centre will have to provide the English translation of the answers.

HSCB will process the answers and provide it to RER-ASSR for the analysis.

RER-ASSR will be in charge to do the analysis, through qualitative methodologies (content analysis).


39

PART I – INFORMATION ABOUT THE PERSON FILLING IN THE FORM:

Health Professional

please specify (maximum 300 characters)

Community actor

Which Sunfrail partner do you belong? (Please indicate)

Lodz HSCB Deusto

R. Liguria Fed. II of Campania RER-ASSR

PART II – UTILIZATION OF THE SUNFRAIL TOOL

1. Did you receive any training concerning the application of the Sunfrail Tool?

YES NO PARTIALLY

If YES, was it useful?

YES NO PARTIALLY


40

Please describe (maximum 300 characters)

2. Which was the setting of application of the Sunfrail Tool? (If the application took place in

multiple settings, please indicate the main one)

Primary health care facility

Hospital / secondary care

Community setting

3. Did you face any difficulties during the application of the Sunfrail Tool? (eg. clear/unclear

instructions; comprehensibility; flexibility of the tool)


4. How was the interaction with the patients/beneficiaries?



41

PART III - APPLICABILITY AND IMPACT OF THE SUNFRAIL TOOL

5. Do you think that the Sunfrail Tool is easily usable to identify frailty according to its main

domains: Biomedical, Psychological, or Socio-economical?

YES NO PARTIALLY

Please provide reason for your answer (maximum 300 characters)

6. Do you think that the Sunfrail Tool can help beneficiaries to identify their potential condition of

frailty?

YES NO PARTIALLY


7. Do you think that the Sunfrail Tool is suitable to activate care pathways (professional

evaluation, diagnostic investigation, preventive activities or support)?

YES NO PARTIALLY


42


8. Do you think that the Sunfrail Tool can be applicable during the daily professional/care

practice? (e.g. Useful/not useful; of support for further activities/obstacle to planned activities

etc.)

YES NO PARTIALLY


9. What aspects could be improved for the application of the Sunfrail Tool during the daily

professional/care practice?



43

Phase 3 - Results of the Assessment of Professionals and Community Actor Opinion on the Use

of the Sunfrail Tool

The assessment of professional and community actor opinion on the use of the Sunfrail Tool was

performed between the months of October and November 2017 in the reference sites of Lodz, HSCB,

Deusto, R. Liguria, Fed. II of Campania Region, with the aim to appraise:

1. Whether the tool is suitable to identify the domains of frailty and to activate care pathways;

2. Whether it is easily understandable and applicable during the daily professional/care practice;

3. Whether it needs to be modified/improved and how.

A short questionnaire including closed and open end questions and was completed in English. HSCB

processed the answers and provided the data to RER-ASSR for the analysis.

24 people were interviewed: 6 from Lodz; 2 from HBSC; 2 from Deusto; 8 from Campania and 6 from

Liguria. 17 were Health Professionals and 6 Community Actors; 1 did not answer the questions.

I) INFORMATION ABOUT THE PERSONS FILLING THE FORM Community Actors: 6 Health Professionals: 17 Missing Data: 1 II) UTILIZATION OF THE SUNFRAIL TOOL TRAINING USEFULNESS Almost all interviewed received (75%)/partially received (21%) the training.

Among them, almost all reported that the training was useful (totally useful: about 86%; partially useful:

about 14%); particularly to clarify the conceptual model based on the multi-domains of frailty; the care-

pathways to be suggested and the information on how to access local services.

The training was also useful to get acquainted with the Sunfrail tool and with the instructions on how to

correctly fill it/how to interact with patients.

Some interviewed (community actors) reported problems with the concept of “referral pathways”, that was

not explained in details during the training sessions.

The training on the Sunfrail tool was performed with different methodologies varying from settings. In

some cases (Liguria), the training was conducted in University classes (Post Graduation in Family and

Community Nursing, Module on Frailty in older adults), or during specific training weeks. In some other

cases (Campania), the training was provided through the training for trainers methodology: workshops held

throughout the project timeframe by Sunfrail Project coordinators, as well as by the trained team to

downstream operators.

DIFFICULTIES ENCOUNTERED DURING THE APPLICATION OF THE TOOL About 54% of the interviewed applied the tool in health care settings. About 46% of the interviewed applied the tool in community settings. All the health professionals interviewed reported no difficulties during the application of the tool in health care settings.


44

In secondary care settings, the tool was administered as part of a comprehensive geriatric assessment. In community settings, some interviewed underlined the need to interact with the patients in a “secure, protected environment”, given the confidential nature of the questions and the delicacy of the issues to be addressed. Furthermore, they pointed out that some sensitive questions could also create difficulties in some cultural settings. Some community actors reported also difficulties in suggesting appropriate pathways, due to difficulties in matching the needs detected and the existing care resources and problems in monitoring the effective results of the referral process, etc). INTERACTION WITH PATIENTS/BENEFICIARIES The totality of the interviewed who applied the tool in health care settings expressed great satisfaction in the interaction with the patients. The tool is defined as a “friendly formula”, not time consuming, flexible, with easy and short questions, very simple to understand. The questions are not stressful and can also encourage a more in-depth dialogue. At the same time, the short “examination time” is non-invasive and allows the application also in everyday clinical practice. The interviewed reported also that a clear explanation of the aims of the tool (combination of “alerts” on pre-frailty/early frailty conditions, and referral to care pathways), helped in raising interest and good predisposition in the beneficiaries. Some interviewed suggested to further simplify some items, considering that some patients have a low education level and needed some clarification (see suggestions below). In community settings, some interviewed reported that beneficiaries were a bit shy, at least at the beginning. A more open-ended approach helped beneficiaries to understand better the aim of the tool and to give more relevant information on frailty risks and on their needs; thus to allow interviewers to provide relevant suggestions on care pathways/access to services etc. III) APPLICABILITY AND IMPACT OF THE SUNFRAIL TOOL FRAILTY IDENTIFICATION ACCORDING TO THE BIOMEDICAL, PSYCHOLOGICAL AND SOCIO-ECONOMICAL DOMAIN The totality of the interviewed reported that the Sunfrail tool helped detecting key aspects of frailty in its three domains (about 83% totally agreed; about 17% partially agreed). The inclusion of items dealing with the economic aspects was considered a distinctive and innovative element. Among the ones who partially agreed, some reported that few questions were vague and/or not always suitable to identify frailty (e.g. deliberate weight loss could be due to a choice of a healthier lifestyle; falls could be caused by accidents like ice during winter; occasional memory loss might not be seen as an early dementia indicator). They suggested that in order to overcome these aspects and to get a true picture of a person’s needs/difficulties it is necessary to stimulate a more in-depth dialogue going beyond the yes/no answers. In general, the Sunfrail tool is described as a really useful screening instrument, that has to be accompanied by a more detailed assessment, like for example the multi-dimensional geriatric assessment. CAPACITY TO PROMOTE BENEFICIARIES AWARENESS According to all the interviewed, the tool can improve beneficiaries’ awareness, helping in identifying needs referred to frailty, and also providing information on how to access assistance and support if required (about 79% totally agreed; and about 21% partially agreed). As suggested before, open-ended questions or a more in-depth approach could help patients discern their potential frailty. Some interviewed reported that, by receiving the Sunfrail tool questions patients become rather “mindful” about their well-being, the importance of self-monitoring, and the existing care pathways in their


45

community. Overall, they were encouraged to move from a “disease” oriented vision, to a “multi-dimensional” concept of frailty. In order to be more effective, some community actors suggested preparing a leaflet with a detailed description of the Sunfrail tool 9 items, explaining how to behave to prevent frailty and its progression. Some interviewed suggested also to administer the questionnaire periodically as a “monitoring” tool. CAPACITY TO ACTIVATE CARE PATHWAYS According to the interviewed, the Sunfrail Tool can help activating pathways for preventive activities and for different types of support (about 83% totally agreed; about 17% partially agreed). The suggested pathways include a wide range of interventions: from the activation of preventive pathways to address frailty risk factors to other types of support available by local services. Some health professionals reported that the identification of frailty risk factors can facilitate the detection

of early signs of unbalance in chronic disease state that can be addressed by specialists through appropriate

interventions/care pathways; thus preventing adverse events and hospitalizations. Some conditions can

also be tackled by preventive activities, such as nutritional interventions, physical activity or physiotherapy,

logotherapy, memory training.

Some interviewed underlined the necessity to map the local available services, in order to provide a

coherent and sustainable responses taking into account existing and accessible care resources. An in-depth

training can be useful to improve this aspect.

APPLICABILITY DURING DAILY PROFESSIONAL/CARE PRACTICE According to all the health professionals interviewed, the Sunfrail tool can be applicable during the daily professional/care practice (about 83% totally agreed; about 17% partially agreed). It is considered easy to be performed, useful in daily practice and supportive for further activities. Overall, professionals suggested using the tool especially in primary care/community settings, by stimulating the dialogue with beneficiaries through more detailed questions aimed to gather an in-depth understanding of their background and needs. The tool is supposed to orient further investigations in secondary care settings. ASPECTS OF THE SUNFRAIL TOOL TO BE IMPROVED The majority of the interviewed reported no aspects to be improved or suggestions on it. Others suggested some points to be addressed, here resumed:

- to add a leaflet with more detailed explanations on the Sunfrail tool items and on the importance to work on frailty primary and secondary prevention;

- to strengthen the connections among the Sunfrail tool items responses and the pathways to be suggested, according to the existent services;

- to administer the tool by using open ended questions, to avoid the risks of misinterpretation of subjects’ needs;

- To integrate the tool with ICT support, and downstream comprehensive geriatric questionnaires, providing information about monitoring and effectiveness of subsequent interventions;

- to explore more the psycho-social domain, through open-ended questions, in particular about the item on cognitive decline;

- to add another question on Self reported Health: “How much do you value your Health from 0 to 10?”.


46

Key points:

The training is proved to be useful and important for both health professionals and community actors, in

particular to clarify the conceptual model based on the multi-domains of frailty; the care-pathways to be

suggested/activated and the information on how to access the different territorial services.

The Tool is reported to be a friendly instrument, easy to apply, in particular in health care settings. Its

questions are simple to understand and can also encourage a more in-depth dialogue. Thanks to the short

“application time”, it is non-invasive and allows the use also in everyday clinical practice.

When approaching the beneficiaries it is important to pay attention to the cultural and social context of

application. When applied in community settings, given the confidential nature of the questions, subjects

should be approached in “secure, protected environments”, with guarantees of privacy.

When used in community, the Sunfrail tool can help identifying frailty risk factors or early frailty conditions,

to be explored with further interventions / assessments (eg: multi-dimensional geriatric assessment). Its

potential for identification of frailty domains and activation of care pathways depends also on the capacity

of the interviewers to gather further information. In order to get a true reflection of the persons

needs/difficulties, it is important to trigger a more in-depth dialogue, with open ended questions that allow

to estimate better patients’ condition.

The tool can help detecting early signs of unbalance in chronic disease state that can be addressed by

specialists with appropriate interventions, thus preventing adverse events and hospitalizations. Some

conditions can also be addressed by preventive activities, such as nutritional interventions, physical activity

or physiotherapy, logo-therapy, memory training. For that purpose, it is also important to strengthen the

connections among the Sunfrail tool items and the pathways to be suggested, by mapping the local

available services, in order to provide coherent and sustainable responses taking into account existing and

accessible care resources.

The tool can improve beneficiaries’ awareness, encouraging them to move from a single “disease” oriented

vision, to a “multi-dimensional” concept of frailty. Open-ended questions could help patients in discerning

their potential frailty and be informed on how to access assistance and support if required.

Date post:	17-Jul-2020
Category:	Documents
Upload:	others
View:	0 times
Download:	0 times

Reference Sites Network for Prevention and Care of Frailty ... · back 6 18.10.2017 RER-ASSR D 6.2...

Documents